Mulongo, P., Hollins Martin, C., McAndrew, S.

(2014) Psychological impact of Female Genital

Mutilation/Cutting (FGM/C) on girls/women’s mental health: a narrative literature review.
Journal of Reproductive and Infant Psychology. 32 (5): 469-85.
Doi.10.1080/02646838.2014.949641

Peggy Mulongo1 MSc DipHE RMN

Caroline Hollins Martin2 PhD MPhil BSc PGCE RMT ADM RGN RM MBPsS

Sue McAndrew3 PhD MSc BSc (Hons) CPN Cert RMN

1 Wellbeing Project Coordinator /Cross-Cultural Mental Health Practitioner, NESTAC Charity.

Main office: 237 Newstead, Rochdale, Lancashire, OL12 6RQ UK. E-mail: peggy@nestac.org

2
Professor in Midwifery, School of Nursing, Midwifery and Social Work, MS2.78, University of
Salford, UK. E-mail: C.J.Hollins-Martin@salford.ac.uk

3
Research Fellow, School of Nursing, Midwifery and Social Work, MS1.39, University of Salford,
UK. E-mail: s.mcandrew@salford.ac.uk

Address for correspondence

Caroline J Hollins Martin, Professor in Midwifery, School of Nursing, Midwifery and Social Work,
MS2.78, University of Salford, UK. E-mail: C.J.Hollins-Martin@salford.ac.uk
1
Psychological impact of Female Genital Mutilation/Cutting (FGM/C) on
girls/women’s mental health: a narrative literature review

Abstract

Background: Female Genital Mutilation/Cutting (FGM/C) is the procedure of removing healthy

external genitalia from girls/women for socio-cultural reasons. There is much scientific literature on
the adverse physical health complications that can result from having FGM/C, but little is known
about its psychological impact and treatment.
Objective: To identify psychological problems that may follow on from a woman having FGM/C
and success of treatment herein, and relate findings to the role of the maternity care professional.
Study Design: A structured narrative review, which identified ten studies was carried out.
Findings: Eight out of ten studies reported psychological consequences, such as Post-Traumatic
Stress Disorder (PTSD) and affective disorders. Also identified were socio-cultural differences in the
meaning of perceived consequences between individuals. Two studies gave inconclusive results
regarding the psychological impact of FGM/C on women’s lives.
Key conclusion: Whilst these findings provide an indication of adverse psychological effects of
women/girls having FGM/C, more studies are needed. In particular, studies that focus on the role that
cutting extent, circumstances surrounding the cutting, and girls’ level of knowledge of what was
going to take place, and their relationships to psychological outcomes.
Implications for Practice: Raising awareness of the risk of negative psychological consequences is
important, with maternal health care professionals requiring training on how to treat and care for
women/girls who are suffering problems that result from having FGM/C.

Key words: anxiety, circumcision, Female Genital Mutilation /Cutting (FGM / FGC), midwifery,
Post-Traumatic Stress Disorder (PTSD), psychological, trauma

2
Psychological impact of Female Genital Mutilation/Cutting (FGM/C) on
girls/women’s mental health: a narrative literature review

Introduction

The World Health Organisation (WHO) (2008) acknowledges that psychological trauma often results

from women having FGM/C, particularly when physical complications are ignored. While midwives

may be considered frontline staff in recognising recipients of FGM/C, the management of

consequent psychological problems and their management require to be developed (Applebaum et

al., 2008; Behrendt & Morritz, 2005; Chibber et al., 2011; Kizilhan, 2011).

Definition of FGM/C

The term FGM/C refers to procedures that involve partial or total removal of the external female

genitalia for non-medical reasons (WHO, 2008). The WHO (2008) has categorised four types of

FGM/C:

Type 1: Partial or total removal of the clitoris and or the prepuce (clitoridectomy).

Type 2: Partial or total removal of the clitoris and the labia minora, with or without excision

of the labia majora (excision).

Type 3: Narrowing of the vaginal orifice with creation of a covering seal by cutting and

appositioning the labia minora and/or the labia majora, with or without excision of

the clitoris (infibulation).

Type 4: All other harmful procedures to the female genitalia for non-medical purposes. For

example, pricking, piercing, incision, labial stretching and cauterisation are

classified under this group.

3
Several names are used to describe FGM/C:

Female Genital Mutilation (FGM) is the term used by most United Nations documents and the

WHO, because it best describes what happens in the act of the practice.

Female Genital Cutting (FGC) is used by the United Nations Children Fund (UNICEF), and other

groups working in practicing communities, since it is seen as a non-judgmental value-neutral term

(Shell-Duncan et al., 2011).

‘Female circumcision’ is the name often given when the practice is translated from an indigenous

language into English. Female circumcision can be misconstrued to be the same as ‘male

circumcision’, where removal of the ‘foreskin’ (prepuce) of the clitoris is seen as equivalent to

removal of the foreskin of the penis (Hastings Center Report, 2012).

An assortment of instruments is used to perform the procedure, which includes knives, glass, razor

blades and scissors (Al-krenawi and Wiesel-Lev, 1999), and increasingly the practice is becoming

‘medicalized’ with doctors and other health professionals performing FGM/C (Pearce and Bewley,

2014; Serour, 2013; Shell-Duncan, 2001).

Requirements for a girl/woman to undergo FGM/C are embedded in traditional beliefs. For example,

some believe that it is a religious requirement (De Lucas, 2004; Keizer, 2003; Nienhuis et al., 2008),

with refusal resulting in a woman being ostracised from her community (Boyle, 2002). An estimated

100-140 million women worldwide have had FGM/C, with around 3 million carried out each year in

Africa alone (Yoda et al., 2013). Approximately 66,000 women who have had FGM/C are living in

England and Wales, with a further 6,500 at risk of having the procedure carried out each year

(Dorkenoo et al., 2007). Performing FGM/C is now considered by the westernized international

community to be a crime, with for example the United Kingdom FGM Act (2003) making it an

4
offence for a resident to conduct the operation either at home or abroad (WHO, 2008). The law

carries a maximum penalty of between 5-14 years imprisonment (Gordon, 2005; WHO, 2008). It is

also possible in the United States of America (USA), United Kingdom and a number of other

European Union countries to be granted asylum based on FGM/C (Kea and Roberts-Holmes, 2013).

Health complications

Regrettably, interventions designed around health messages have not led to FGM/C abandonment.

Instead, changes have moved from more to less extensive forms of FGM/C, or medicalization of the

practice. Types 1, 2 and 3 can accrue physical consequences, such as haemorrhage, infection, chronic

pain, dysuria, pelvic inflammatory disease, keloid scarring, sexual dysfunction, infertility, and birth

complications (Alsibiani, 2010; Banks et al., 2006; Behrendt and Moritz, 2005; Dare et al., 2004;

Toubia, 1995). Whilst in contrast, other studies report positive outcomes, which include enhanced

sexual desire, arousal, orgasm, satisfaction and more frequent sexual activity (Ahmadou, 2009;

Catania, 2007; Esho et al., 2010).

It is often at the onset of pregnancy and/or during childbirth that the effects of FGM/C

become problematic, with midwives often the first health care professionals to recognise that the

woman has had the procedure. Although midwives do not have long-term involvement with their

clients, their offering support and empathy for complications of FGM/C may prompt help-seeking

behaviours (Momoh et al., 2001; Lundberg and Gerezgiher., 2008). With this in mind, the objective

of this study was to identify psychological problems that may follow on from a woman having

FGM/C and success of treatment herein, and relate findings to the role of the maternity care

professional.

5
Method

A narrative review of the literature was considered the most suitable method to respond to the

objective of this study. This is because a narrative review is intended to survey the state of

knowledge on a particular topic. Such reviews provide useful overviews and integrations of an area,

and as such can be valuable as a means of pulling together what is known about a particular

phenomenon, such as for a grant proposal, or as a resource to teachers. A further purpose of a

narrative literature review is problem identification. The purpose is to reveal problems, weaknesses,

contradictions, or controversies in a particular area of investigation. The author may venture some

tentative solutions to the problems he or she identifies, but is more concerned with simply informing

the field that some difficulty exists. Thus, such articles typically raise more questions than they

answer, leaving it to future researchers to straighten out the predicaments. Still, identifying problems

in the empirical literature can serve a valuable scientific function (Baumeister and Leary, 1997).

Having justified choice of method, the aim of this study was to educate maternity care professionals

about the state of knowledge on the topic FGM/C and its psychological consequences and treatment,

and identify where the literature requires to be developed. Also, to apply these findings to help

midwives deliver more effective care to women with FGM/C.

Search strategies derived from Brettle and Grant’s (2004) guidelines were followed. This

approach involved combining Medical Subject Headings (MeSH) with terminology that relates to

FGM/C, psychological impact and therapeutic interventions. Keywords included; FGM, Female

Genital Mutilation/Cutting, Female Circumcision, psychology, psych*, therapies, interventions,

mental health and well-being. Abstracts of Reviews of Effects (DARE) (CRD, 2008) and the

Cochrane Database of Systematic Reviews (CDSR) (Cochrane Library, 2008) were searched.

Databases explored included MEDLINE (R), PsychINFO, PsycARTICLES Full Text and

PsycEXTRA and CINAHL). An internet search of Google Scholar, African Index Medicus, WHO,

Population Reference Bureau (PRB) and searches of academic literature, journals and reference lists
6
were carried out. In order to capture relevant studies, the inclusion criteria was limited to all

published research relating to psychological consequences of FGM/C, and success of therapeutic

interventions used to treat women with FGM/C. Systematic Reviews, Qualitative Studies, Cohort

Studies, Case-Control Studies, Randomised Controlled Trials and Cross-Sectional Studies were

included. Inclusion criteria were as follow:

 Population: girls and women of all age and nationalities from FGM/C practicing

communities affected by the procedure, as classified by the WHO (2008).

 Intervention: psychological consequences and therapeutic interventions available for

girls/women with FGM/C.

 Comparison: Young girls and women who had not undergone any type of FGM/C, as

defined by the WHO (2008) were compared to those who have been subjected to any

type of FGM/C.

 Outcome: Combinations of words and phrases included: health terms such as

psychology, psychosocial, emotional repercussions of FGM/C, therapeutic

interventions for FGM/C victims, cognitive behaviour, mental health and wellbeing,

trauma, depression, anxiety, mental health problems. Specific terms such as migrant

women’s health, asylum seekers/refugee women, or FGM/C practicing communities

were also included, as well as occupational terms such as mental health care,

psychologists, cross-cultural interventions, psychosocial therapy and counselling.

The search was conducted between Jan-May 2013 by the first author, under supervision of the other

authors. All titles, abstracts and full-text of studies resulting from the search process were screened

for inclusion, and those irrelevant were rejected. The search strategy integrated medical subject

heading - MeSH- (Brettle and Grant, 2004), terms and text words related to FGM, psychological

impacts and therapeutic interventions. The keywords comprised ‘Female Genital Mutilation’,

7
‘Female Genital Mutilation/Cutting’; ‘Female Circumcision’; ‘psychology’, ‘psych*’, ‘therapies’,

‘interventions’, ‘mental health and wellbeing’; and several combinations of the above. A total of

1034 papers were retrieved (see Table 1). To ensure the study remained focused, the inclusion

criteria were strictly adhered to. In doing so the search was limited to all published research that

related to psychological and mental health consequences from having FGM/C and therapeutic

interventions used in practice.

TABLE 1 HERE

To view the search strategy terms (see Table 2) and a flowchart of selected studies (see Figure1).

TABLE 2 HERE

FIGURE 1 HERE

Findings

Out of the 1034 studies retrieved, only 10 papers reported psychological effects from having FGM/C.

To view a summary of the studies included (see Table 3).

TABLE 3 HERE

What is the difference between this review and others?

In a prior systematic review by Berg et al. (2010), the research team asked what the psychological,

social and sexual consequences of having FGM/C were. Berg et al. (2010) concluded that the

evidence-base was insufficient to draw meaningful conclusions. With similar interest to Berg et al.

(2010), we wanted to explore the psychological consequences from having FGM/C and its treatment,

but expand focus to relate to the role of maternity care experts. In essence, this narrative review has

been written to inform midwives that the area of psychological treatment of FGM/C requires

improved, tried and tested methods to advance care for childbearing women. In particular, midwives

encounter problems directly related to childbearing women with FGM/C, and a broad overview of

relevant information has been presented specifically to develop their practical understanding of
8
potential psychological problems that may ensue. We have included the systematic review of Berg et

al. (2010), because it highlights that a paper is available that has used a system to grade papers, and

as such can be referred to if required.

Results

All of the studies listed in Table 4 omit to discuss psychological interventions specifically designed

to treat women with psychological problems as a direct consequence of having FGM/C. Although

several studies acknowledge that psychological consequences can result, the majority only indicate

need to develop culturally adapted therapies to support experiencers, and specialist training for

psychologists/counsellors already working with this specific group of women. Although there is no

study that focuses specifically upon therapeutic interventions, potential psychological consequences

were discussed within the 10 identified papers.

Psychological outcomes identified in the literature

Out of the ten studies identified, five solely addressed psychological consequences from having

FGM/C (Al-Krenawi and Wiesel-Lev, 1999; Applebaum et al, 2008; Behrendt and Morritz, 2005;

Kizilhan, 2011; Nnodum, 2002), whilst the other five included this as just one component amongst

many outcomes (Berg et al, 2010; Chibber et al., 2011; Elnashar and Abdelhady, 2007; Osinowo and

Taiwo, 2003; VIoeberghs et al, 2011). Details of findings from the ten studies included elements of

the Population, Intervention, Comparison and Outcome(s) (PICO) framework with results

summarised in Table 3. The following psychological problems were acknowledged in the literature.

Post-Traumatic Stress Disorder (PSTD)

Six studies (Behrendt and Morritz, 2005; Applebaum et al., 2008; Chibber et al., 2011; Kizilhan,

2011; Nnodum, 2002; VIoeberghs et al., 2011) provided data on the prevalence of PTSD for women

with FGM/C. Applebaum et al. (2008) was the only study that found no significant difference

9
between (n=19) circumcised Bedouin women and (n=18) age-matched controls in terms of

psychological consequences. Behrendt and Morritz (2005) reported that 30.4%, Kizilhan (2011)

44.3%, Chibber et al. (2011) 30%, and VIoeberghs et al. (2011) 16% of women experience PTSD

from having had FGM/C. Vloeberghs et al. (2011) identified that Sudanese women experience

higher levels of PTSD compared with those from Somalia, Eritrea and Sierra Leone.

Affective disorders

Some women report experiencing affective disorders post FGM/C, which includes somatization,

anxiety and phobia (Elnashar and Abdelhady, 2007). Behrendt and Morritz (2005) report that 47.9%

of the women in their study developed affective and anxiety disorders. In comparison, Chibber et al.

(2011) reported that 58% of the women in their study experienced affective disorders and 38%

anxiety symptoms. To contradict these findings, Kizilhan (2011) reported no significant difference in

development of affective disorders between the FGM/C group and their control. Berg et al. (2010)

undertook a meta-analysis (n=12,755) of the results of studies that measured levels of anxiety,

somatisation, depression and hostility, and also found no significant difference between groups. Such

contradictions in findings between these reports make it difficult to draw meaningful conclusions.

Socio-cultural differences in the meaning of perceived consequences

Berg et al. (2010) recognised that women with FGM/C are more likely to experience marital

dissatisfaction. Vloeberghs et al. (2011) identified that many women consider themselves ordinary,

with FGM/C viewed as an integral part of their social convention. Such women find it easier to

accept their situation, believing that consequent problems represent the norm (Lockhat, 2004).

Vloeberghs et al. (2011) found no associations between socio-economic background and reports of

mental ill-health, with no differences between marital status, type of marriage (arranged or choice),

educational background, family makeup and PTSD, anxiety and depression. Participants’

experiences of support/care from mental health providers was generally positive (Vloeberghs et al.,
10
2011), with all ten studies recommending that health professionals working in communities

practising FGM/C receive specialised training.

Discussion

This review has confirmed that little empirical research has focused specifically upon psychological

problems that can follow on from having FGM/C (Jaeger et al., 2002; Purchase et al., 2013). Two

studies were inconclusive (Applebaum et al., 2008; Berg et al., 2010) and eight supported firm

associations between having FGM/C and development of subsequent psychological problems (Al-

Krenawi and Wiesel-Lev, 1999; Behrendt and Morritz, 2005; Chibber et al., 2011; Elnashar and

Abdelhady, 2000; Kizilhan, 2011; Nnodum, 2002; Osinowo and Taiwo, 2003; VIoeberghs et al.,

2011). Types of FGM/C alters the extent of psychological effects, with women who report high

trauma more likely to have had Type 3 FGM/C (Obermeyer, 1999; Yoder and Khan, 2008).

Raising awareness of the risk of negative psychological consequences is important for health

care professionals to do their job effectively. In particular, midwives require training about how to

treat and care for women suffering psychological problems that result from having FGM/C, because

their work relates directly to this locale. They also require to understand genesis and customs

surrounding FGM/C (Momoh et al., 2001; Whitehorn et al., 2002), with knowledge embedded into

curricula of professional degree programs. Care providers must acknowledge that having FGM/C

may be considered by family members to be in the woman’s best interests, with cultural reasons for

performing including:

 Preparation for adulthood and marriage (Yoder et al., 1999; Ahmadu, 2000).

 Gaining entry into women’s secret societies (Ahmadu, 2000; Behrendt and Moritz,

2005).

 Social pressure from peers and fear of stigmatisation and rejection from the

community (Centre for Reproductive Rights 2003).

11
  Beauty and cleanliness (Toubia, 1995).

 Pride and rewards, such as celebrations, public recognition and receiving gifts

(Behrendt and Moritz, 2005).

As such, it is important to acknowledge that socio-cultural rewards are attached to the custom

of FGM/C, which incorporates beliefs, behavioural norms, customs, rituals, social hierarchies,

religious practices, political beliefs and economic systems (Momoh, 2005). Preserving virginity is

just one of the more durable beliefs that direct the practice (Berggren et al., 2006; Gruenbaum,

2006). In some communities FGM/C is performed to ensure marital fidelity and prevent sexual

activity that is considered to be deviant or immoral (Ahmadu, 2000; Gruenbaum, 2006). Such beliefs

must be considered against a backdrop of well-documented complications that can arise during

pregnancy, childbirth and the post-partum period (Daley, 2004; Momoh, 2005; Zaidi, 2007;

Lundberg and Gerezgiher, 2008). When working with childbearing women from communities where

FGM/C is custom, particular questions must be sensitively asked. A female interpreter trained to

understand the complexities is an asset. Processes of questioning must be non-judgemental and

include whether or not the woman:

 Has had FGM/C and if so what type?

 Experiences pain during intercourse?

 Experiences pain or difficulty passing urine (dysuria)?

 Experiences pelvic pain?

 Has problems with menstruation?

 Has experienced difficulties with prior births?

 Is suffering psychological consequences from having FGM/C?

An individualised care plan for pregnancy, delivery and the postnatal period should be generated in

conjunction with the woman. Deinfibulation to reverse Type 3 FGM/C may need to be performed

12
around 20 weeks gestation to diminish risk of miscarriage and permit healing prior to childbirth, with

this having potential to create yet again more psychological trauma. Some women opt for this

incision during labour to circumvent experiencing two episodes of pain and healing, with

deinfibulation performed by a trained professional with experience of incising FGM/C.

Health professionals play a crucial role in safeguarding young girls from procuring the illegal

enactment of FGM/C. For example in the UK, when a childbearing woman presents with FGM/C

and she has a younger sister, relative or friend at risk of having the procedure, the midwife is

required to complete a Multi Agency Risk Assessment Form (available at:

http://www.caada.org.uk/resources/resources.html), which is completed and handed to the

safeguarding officer in the maternity unit. Post-completion, this form is forwarded to the Children

and Family Services (Social Services) for social work action. When a midwife is uncertain of the

processes involved, they must approach their manager/supervisor for advice. Also for example, the

Royal College of Midwives (RCM) has published FGM/C guidelines (available at:

http://community.rcm.org.uk/consultations/female-genital-mutilation-practice-guidelines-

professionals). During process, midwives must respect the woman’s cultural beliefs and provide

information, and choice and control in relation to decisions made.

Strengths and Limitations

One strength of this narrative review is that psychological morbidity has been recognised as a real

problem for women with FGM/C. Researchers require to develop culturally sensitive and appropriate

tools to measure psychological well-being of women with different types of FGM/C, with for

example guidelines made available to advise professionals about FGM/C (e.g., Scotland.gov.uk,

2014; Professionals Working in Ireland, 2013). Further exploration of perceptions of meanings about

psychological well-being and sexual health are required (Jaeger et al., 2002; Purchase et al., 2013), in

both African and European contexts. Another limitation is that the studies reviewed have focused on

13
European countries where women with FGM/C live as immigrants. Research findings should also

focus on informing policy and practice in countries where FGM/C is a cultural ritual.

Conclusion

This narrative review has validated that FGM/C experiencers’ can encounter psychological

consequences from having had FGM/C, which is intertwined with suffering incurred from

physiological complications. Lack of research about cause and effect of difficulties and beneficial

psychological interventions has prohibited inventorying firm conclusions about what may or may not

aid recovery. Extent of a woman’s suffering will inevitably relate to the type of FGM/C she has had,

complications that have arisen and the socio-cultural context of her belief system, marital

relationship, and support networks. Those working in reproductive health are best placed to initiate

and facilitate support for women with FGM/C both in the immediate and future context. Whilst

findings of this narrative review provide an indication of adverse psychological effects from having

FGM/C, many more studies are needed. In particular, ones that focus on the role that cutting extent,

circumstances surrounding the cutting, and girls’ level of knowledge of what was going to take place

might play on adverse psychological outcomes. Providing clearer evidence about therapeutic

interventions for effectively treating psychological trauma post FGM/C is a clear requirement to

meet the changing needs of this distinctive population of women.

14
References

Ahmadu, F.S., & Shweder, R.A. (2009). Disputing the myth of sexual dysfunction of circumcised
women: interview with Richard Shweder. Anthropology Today, 25(6), 14-19.

Al-krenawi, A., & Wiesel-Lev, R. (1999). Attitudes toward and perceived psychosocial impact of
female circumcision as practiced among the Bedouin-Arabs of the Negrev. Family Process,
38(4), 431-443.

Alsibiani, S.A., & Rouzi, A.A. (2010). Sexual function in women with female genital mutilation.
Fertility and Sterility, 93(3), 722-724.

Applebaum, J., Cohen, H., Matar, M., Abu Rabia, Y., & Kaplan, Z. (2008). Symptoms of
Posttraumatic stress disorder after ritual female genital surgery among Bedouin in Israel: Myth or
reality? Primary Care Companion Journal Clinical Psychiatry. 10(6), 453-6.

Banks, E., Meirik, O., Farley, T., & Akande, O. (2006). Female genital mutilation and obstetric
outcome: WHO collaborative prospective study in se African countries. The Lancet, 367, 1835-
1841.

Baumeister, R.F., Leary, M.R. (1997). Writing Narrative Literature Reviews. Review of General
Psychology, 1(3), 311-320

Behrendt, A., & Moritz, S. (2005). Post-traumatic stress disorder and memory problems after female
genital mutilation. American Journal of Psychiatry, 162, 1000-1002.

Berg, R.C., Denison, E., & Fretheim, A. (2010). Psychological, social and sexual consequences of
female genital mutilation/cutting (FGM/C): A systematic review of quantitative studies. Oslo,
Norway: Norwegian Knowledge Centre for the Health Services (NOKC).

Berggren, V., Yagoub, AE., Satti, AM., Khalifa, MA., Aziz, FA., & Bergstrom, S. (2006).
Postpartum tightening operations on two delivering wards in Sudan. British Journal of
Midwifery, 14, 1-4.

Boyle, E. (2002). Female genital cutting: Cultural conflict in the global community. Baltimore: The
Johns Hopkins University Press.

Brettle, A., & Grant, M.J. (2004). Finding the evidence for practice: a workbook for health
professionals. London: Churchill Livingstone.

British Medical Association (BMA). (2008). Access to healthcare for asylum and refused asylum
seekers. London: BMA.

Catania, L. (2007). Pleasure and orgasm in women with Female Genital Mutilation/Cutting
(FGM/C), Journal of Sexual Medicine. 4, 1666-78.

Centre for Reproductive Rights (2003). Female Circumcision/Female genital mutilation (FC/FGM):
Legal prohibitions worldwide (fact sheets). http://www.crlp.org/pub_fac_fgmicpd.html

15
Chibber, R., El-Saleh, E., & J. El Harmi, J. (2011). Female circumcision: obstetrical and
psychological sequelae continues unabated in the 21st century. Journal of Maternal-Fetal &
Neonatal Medicine, 24(6), 833-6.

Cochrane Library (2008). Chichester: Wiley. www3.interscience.wiley.com/cgibin/mrwhome/

106568753/HOME

Critical Appraisal Skills Programme (CASP) (2006). Critical appraisal tools to make sense of
evidence. National Collaborating Centre for Methods and Tools (2011). Critical appraisal tools
to make sense of evidence. Hamilton, ON: McMaster University.

Daley, A. (2004). Female genital mutilation: consequences for midwifery. British Journal of
Midwifery, 12(5), 292-298.

Dare, F.O., Oboro, V.O., Fadiora, S.O., Orji, E.O., Sule-Odu, A.O., & Olabode, T.O. (2004). Female
genital mutilation: An analysis of 522 cases in South-Western Nigeria. International Journal of
Gynecology & Obstetrics, 24(3), 281-83.

De Lucas, J. (Eds.). (2004). Evaluating the impact of existing legislation in Europe with
regard to female genital mutilation. Valencia (University of Valencia), Spain: Spanish
National Report.

Dorkenoo, E., Morison, L., & Macfarlane, A. (2007). A statistical study to estimate the prevalence of
Female Genital Mutilation in England and Wales: FORWARD. London: DoH.

Elnashar, A., & Abdelhady, R. (2007). The impact of female genital cutting on health of newly
married women. International Journal of Gynecology & Obstetrics, 97(3): 238-44.

Esho, T. (2010). Female genital cutting and sexual function: in search of an alternate theoretical
model. African Identities, 8(3), 221-35.

Gordon, H. (2005). A clinician’s experience. In: C. Momoh, Female genital mutilation (p. 29-42).
Radcliffe: Milton Keynes, UK.

Gruenbaum , E. (2001). The female circumcision controversy: an anthropological perspective.

Pittsburgh, USA: University of Pennsylvania Press.

Hastings Center Report. (2012). The public policy advisory network on female genital surgeries in
Africa: seven things to know about female genital surgeries in Africa. Hastings Center Report 42,
42(6), 19–27.

Horwitz, R.I. (1995). Large-scale randomized evidence: large, simple trials and overviews of trials:
discussion. A clinician’s perspective on meta-analyses. J Clin Epidemiol, 48: 41-4.

Jaeger, F., Schulze, S., Hohlfeld, P. (2002). Female genital mutilation in Switzerland: a
survey among gynaecologists, Swiss Med Wkly. 132, 259-4.

16
Kea, P.J., & Roberts-Holmes, G. (2013). Producing victim identities: female genital mutilation and
the politics of asylum claims in the United Kingdom. Identities: Global Studies in Culture and
Power, 20(1), 96-113.

Keizer, C. (2003). Acculturation and psychic effects of female circumcision: a research on key
persons and representatives own language and culture of the Somali community in the NL.
Netherlands: Psychology.

Kizilhan, J.I. (2011). Impact of psychological disorders after female genital mutilation among
Kurdish girls in Northern Iraq. The European Journal of Psychiatry, 25(2), 92-100.

Lockhat, H. (2004). Female Genital Mutilation: treating the tears. London: Middlesex University
Press.

Lundberg, P. C., & Gerezgiher, A. (2008). Experiences from pregnancy and childbirth related to
female genital mutilation among Eritrean immigrant women in Sweden. Midwifery, 24(2), 214-
225.

Momoh, C., Ladhani, S., Lochrie, D. P., & Rymer, J. (2001). Female genital mutilation: analysis of
the first twelve months of a southeast London specialist clinic. British Journal of Obstetrics and
Gynaecology, 108(2), 186-191.

Momoh, C. (2005). Female Genital Mutilation. Radcliffe Publishing: Oxford, UK.

Nienhuis, G., Hendriks, M., & Naleie, Z. (2008). Zware dingen moet je voorzichtig duwen:
achtergronden gevolgen en aanpak meisjesbesnijdenis (2e herziene druk). Utrecht, Amsterdam:
Pharos/FSAN.

Nnodum, B.I. (2002). Female genital mutilation and its effects: Implications for counselling. The
Nigerian Journal of Guidance & Counselling, 8(1), 112-132.

Obermeyer, C.M. (1999). Female genital surgeries: the known, the unknown, and the unknowable. Medical
Anthropology Quarterly, 13(1), 79–106, 1999.

Osinowo, H.O., & Taiwo, A.O. (2003). Impact of Female Genital Mutilation on sexual functioning,
self-esteem and marital instability of women in Ajegunle. IFE Psychologia: An International
Journal, 11(1), 123-30.

Pearce, A.J., Bewley, S. (2014). Medicalization of female genital mutilation. Harm reduction or
unethical? Obstetrics, Gynaecology & Reproductive Medicine, 24(1), 29–30.

Professionals Working in Ireland (2013). Female Genital Mutilation (FGM). Information for health-
care professionals working in Ireland. This document was recently updated in June. Dublin,
Ireland: AkiDwA.

Purchase, T.C.D., Lamoudi, M., Colman, S., Allen, S., Latthe, P., & Jolly, K. (2013). A survey on
knowledge of female genital mutilation guidelines. Acta Obstet Gynecol Scand., 92,858–861.

Scotland.gov.uk (2014). Available at: www.scotland.gov.uk/Topics/People/Equality/violence-

17
 women/MinorityEthnicIssuesPages/FemaleGenitalMutilation

Serour, G.I. Medicalization of female genital mutilation/cutting. African Journal of Urology, 19,
145–149

Shell-Duncan, & B. (2001). The medicalization of female circumcision: Harm reduction or

promotion of a dangerous practice? Social Science &Medicine, 52(7), 1013–28.

Shell-Duncan, B., Wander, K., Hernlund, Y., & Moreau, A. (2011). Dynamics of change in the
practice of female genital cutting in Senegambia: Testing predictions of social convention
theory. Social Science and Medicine, 73, 1275-1283.

Toubia, N. (1995). Female genital mutilation: a call for global action (p. 24-25). New York, USA:
Rainbow.

Vloeberghs, E., Knipscheer, J., Kwaak van der, A., Naleie, Z., & Muijsenbergh van den, M. (2011).
Veiled pain: Study in the Netherlands on the psychological, social and relational consequences of
female genital mutilation. Utrecht, Netherlands: Pharos.

Whitehorn, J., Ayonrinde, O., & Maingay, S. (2002). Female Genital Mutilation: cultural and
psychological implications. Sexual and Relationship Therapy, 17(2), 161-170.

World Health Organization (WHO). (2008). Eliminating female genital mutilation: An interagency
statement, OHCHR, UNAIDS, UNDP, UNECA, UNESCO, UNFPA, UNHCR, UNICEF,
UNIFEM, WHO. Geneva: WHO.

Yoder, P.S., & Kahn, S. (2008). Numbers of women circumcised in Africa: the production of a total.
Washington: United States Agency for International Development DHS working papers.

Yoder, P.S., Wang, S., & Johansen, E. (2013). Estimates of female genital mutilation/cutting in 27
African countries and Yemen. Studies in Family Planning, 44(2), 189–204

Zaidi, N., Khalil, A., Roberts, C., & Browne, M. (2007). Knowledge of female genital mutilation
among healthcare professionals. Journal of Obstetrics & Gynecology, 27(2), 161-164.

18
Table 1: Search results for databases

DATABASE HITS RELEVANT STUDIES FOR

INCLUSION

Cochrane 3 1

Centre for Reviews and 4 1

Dissemination (CRD)

DARE (1)

HTA (Health technology

assessment) (3)

PubMed (NCBI) 397 2

Ovid SP(Cross search of 4 15 12

databases):

-MEDLINE(R): 1946 to
January Week 4 2013,

-PsycINFO: 1967 to January

Week 5 2013,

-PsycARTICLES Full Text,

-PsycEXTRA 1908 to January

28 2013

(Search story attached)

EBSCO (Cross search of 3 Academic Search Premier Academic Search Premier (6)
databases): (58)
MEDLINE (0)
-Academic Search Premier MEDLINE (43)
CINAHL (0)
- MEDLINE CINAHL (17)

- CINAHL

AB ( fgm or fgc or female

circumcision ) AND AB
psycho*

Reference, hand searching of BMJ: 10 BMJ (0)

key journals, and Internet:
(No records from other visited The British Library: 5 The British Library (0)
sources).
WHO Library: 482 WHO Library (0)

Total number of papers: 1034

19
Table 2: Search strategy terms – Medical Subject Headings and text words

MeSH terms Additional, associated text words

A: Nursing
Mental Health Nursing FGM specialist clinics/ services
Mental Health care
Health care professionals

B: Study aim Culturally Adapted Intervention(s)

FGM Critical appraisal
Evidence‐based practice: FGM health
consequences/interventions
Literature review
C: Study design Systematic review
Systematic review

D: Mental health Well‐being

Mental health Social exclusion / socially excluded
Mental disorders Pre‐existing mental illness
Stress, trauma, psychological / Anxiety Well‐being / well‐being / wellness

E: Therapeutic intervention(s)
Counseling Well Women Clinics
Psychiatric/psychological interventions Specialist/adapted/cultural Intervention(s)
Cognitive Behaviour Therapy
Cultural counselling/psychology Black and Minority Ethnic (BME) population
African women
F: Vulnerable groups
FGM practicing communities
Migrant women populations
Emigrants and Immigrants / Refugees, Asylum seekers

Search Plan
Search 1 – A and B and C and D
Search 2 – A and B and C and E
Search 3 – A and B and C and F

20
 Table 3: Details of summary of findings from included studies

Study Study Participants Study design Intervention Outcomes Results

method
quality
Al-Krenawi Moderate 24 participants Cross No Psychosocial impacts Structured
and Wiesel- (aged 18-36 yrs) sectional psychosocial of FGM. questionnaire revealed
Lev (1999) from Bedouin- comparative and/or Instrument: a structured that: circumcised
Arabs of the Negev, study psychological/ questionnaire, and a women gave
Israel: 12 mental health semi-structured open- legitimization and
circumcised women treatments ended interview cognitive
compared to 12 suggested. rationalization to it.
uncircumcised Semi-structured
women, but who interview revealed
had witnessed or that: circumcised
been told about the women reported
practice. narcissistic insult;
described PTSD,
direct negative
influences, and
emotional difficulties
during the research
interviews. The
findings indicate that
they had difficulties in
mother-daughter
relationships and trust.

Applebaum et Moderate 37 participants: 19 Cross- No PTSD, general No statistically

al. (2008) circumcised sectional psychosocial psychiatric illnesses, significant differences
Bedouin women comparative and/or impact of event, quality were found between
compared to 18 study of life. the 2 groups.
psychological/
age-matched Instrument: PTSD
uncircumcised mental health Scale, Symptom
women, from treatments Checklist, Impact of
March to July 2007 suggested. Event Scale and a
demographics and
background
questionnaire
Behrendt and High 47 participants: 23 Cross- No PTSD, other anxiety The circumcised
Morritz circumcised sectional psychosocial disorders, affective women showed a
(2005) Senegalese women comparative and/or disorders, psychiatric significantly higher
compared to 24 study Diagnoses. prevalence of PTSD
psychological/
uncircumcised Instrument: Mini (30.4%) and other
women in Dakar, mental health International psychiatric syndromes
Senegal. treatments Neuropsychiatric (47.9%) than the
suggested. Interview. uncircumcised
women. PTSD was
accompanied by
memory problems.
Berg et al High women who had Systematic No Psychological There is insufficient
(2010) been subjected to review of psychosocial consequences of evidence to draw solid
FGM/C with quantitative and/or FGM/C. conclusions
women who had not studies psychological/ Instrument: Checklists; concerning
been subjected to mental health Mantel-Haenszel psychological
FGM/C. treatments random effects meta- consequences. Results
12,755 participants suggested. analyses for from psychological
from communities dichotomous outcomes studies suggested that
21
 where FGM/C is and inverse variance circumcised women
practiced, in random effects meta- may be more likely
Norway. analyses for continuous than uncircumcised
outcomes; GRADE. women to experience
psychological
disturbances.

Meta-analyses for
anxiety, somatisation,
depression, and
hostility failed to
reach significance and
were soiled by high
heterogeneity.
Chibber et al. Moderate 4800 pregnant Cross- No Cognitive and Psychiatric sequelae
(2011) women over a 4- sectional psychosocial emotional effects of included: 80%
year period. comparative and/or FGM. continued to have
The mean age of study psychological/ Instruments: the Mini flashbacks to the FGC
participants was 23: mental health international Neuro- event; 58% had a
range 15-46 years. treatments psychiatric interview psychiatric disorder
Women are from suggested. and Rey memory test (affective disorder);
Egypt, Somalia, 38% had other anxiety
Sudan, Nigeria, disorders, and 30%
Senegal and had post-traumatic
Uganda. stress disorder.
FGM is associated
with psychiatric
sequelae. Many will
need psychiatric as
well as gynecological
care.
Elnashar and Moderate 264 circumcised Cross- No Somatisation, anxiety, Circumcised females
Abdelhady newly married sectional psychosocial phobia, depression, had significant mental
(2007) women in Benha comparative and/or hostility. problems such as
City, Egypt. study Instrument: Symptom somatization, anxiety
psychological/
Checklist-90. and phobia (P<0.001).
mental health
treatments
suggested.

Kizilhan Moderate 79 circumcised Cross- No PTSD and general Circumcised girls

(2011) Kurdish girls who sectional psychosocial psychiatric illnesses. showed a significantly
were between 8 and comparative and/or Instrument: higher prevalence of
14 years of age, in study psychological interview PTSD (44.3%),
psychological/
Northern Iraq: and further depression disorder
Thirty mental health questionnaires (33 6%), anxiety
uncircumcised girls treatments disorder (45 6c7c) and
from the above area suggested. somatic disturbance
and thirty-one (36 1%) than the
uncircumcised girls uncircumcised girls.
from other areas of No significant
Iraq differences between
the two control groups
was found.

Nnodum Poor There are no details Cross- No Depression amongst Circumcised women
(2002) given on sectional psychosocial circumcised women Vs. experience depression
participants, study comparative non-circumcised more than
22
 was based in study and/or women. uncircumcised
Nigeria. psychological/ Three null hypotheses Women.
mental health guided the study.
Instrument: T-test
treatments
statistics.
suggested.

Osinowo & Moderate 99 participants: 53 Cross- No Self-esteem. Circumcised women

Taiwo (2003) circumcised women sectional psychosocial Measurement: Single expressed statistically
compared to 46 comparative and/or item. significant lower self-
uncircumcised study psychological/ esteem (t=2.6, df=97,
women, in mental health p<.01) compared with
Ajengule, Nigeria. treatments the uncircumcised
suggested. women.
Psychological
treatment especially
post-traumatic stress
disorder intervention
for circumcised
women is
recommended.
VIoeberghs et High 66 circumcised Mixed method No therapeutic PTSD, general 1/3 of the circumcised
al. (2011) women originating approach: interventions psychiatric illnesses, women met criteria for
from 5 different qualitative and reported. and potential risk affective or anxiety
African countries: quantitative factors. disorders; 16% of the
Somalia, Ethiopia, data. Instrument: in-depth subjects presented
Sudan, Eritrea, and interview and 4 PTSD indices; A
Sierra Leone. standardized lively memory of the
They have all questionnaires. circumcision, an
migrated to the avoidant coping style,
Netherlands. infibulation as type of
Selection of women circumcision were
through snowball amongst significant
sampling. factors associated with
psychopathology.
Somali women
reported the least
problems.

23
 Figure 1: Flowchart for selected studies

1034 papers considered from 656 excluded

initial database search

378 papers screened: 358 papers excluded

titles/abstracts as not meeting criteria

20 papers considered
for final inclusion

10 papers excluded due to:

- 2 relevant records not
10 papers included obtained in full text
- 5 duplicates removed
- 3 papers did not report
psychological consequences
and/or psychological
treatments for FGM

24